1. Time to Caesarean Section: Is the 30-minute guideline appropriate? Dr. Angela Naismith, MD, CCFP Supervisor: Dr. Lynn Murphy Kaulbeck, MD, FRCSC Oct 16 th, 2006 NAPCRG (Tucson, Arizona)

2. Acknowledgements Thanks to Dr. Jeff Dempster and Dr. Charlie Hamm for their contribution to the initiation of this study Thanks to Dr. Jeff Dempster and Dr. Charlie Hamm for their contribution to the initiation of this study

3. Background 2000/01 C/S rate - 22.1%. 1 2000/01 C/S rate - 22.1%. 1 15.2% of deliveries were by emergency C/S. 1 15.2% of deliveries were by emergency C/S. 1 SOGC: recognizes that in such cases of maternal fetal compromise, necessitating timely Caesarean section, an approximate time frame of 30 minutes may be required to assemble the team and commence laparotomy. 2 SOGC: recognizes that in such cases of maternal fetal compromise, necessitating timely Caesarean section, an approximate time frame of 30 minutes may be required to assemble the team and commence laparotomy. 2 1 Liu, 2004; 2 SOGC

4. Background Immediate fetal outcomes with prognostic value include cord pH and Apgar scores Immediate fetal outcomes with prognostic value include cord pH and Apgar scores A cord pH <7.00 strongly correlates with poor fetal outcome such as NICU admission, need for resuscitation or low Apgar scores. 3 A cord pH <7.00 strongly correlates with poor fetal outcome such as NICU admission, need for resuscitation or low Apgar scores. 3 5-min Apgar scores of 0-3 - significantly associated with neonatal death. 4 5-min Apgar scores of 0-3 - significantly associated with neonatal death. 4 3 Victory, 2004; 4 Casey, 2001

5. Methods Retrospective cohort chart review Retrospective cohort chart review 100 charts from Moncton City Hospital 100 charts from Moncton City Hospital Primary outcome: time to C/S Primary outcome: time to C/S Secondary outcomes: Secondary outcomes: 1. To assess impact of interval time to C/S on 1 and 5 minute Apgars and umbilical artery pH. 2. To assess whether time of day when decision made influenced time to C/S. 3. To assess if indication for C/S impacted on time to C/S.

6. Methods Inclusion criteria Inclusion criteria Fetal indications: significant antepartum hemorrhage, fetal distress, abruptio placenta Fetal indications: significant antepartum hemorrhage, fetal distress, abruptio placenta Maternal indications: HELLP, PIH, acute mat. illness, previous C/S contraindicating labour Maternal indications: HELLP, PIH, acute mat. illness, previous C/S contraindicating labour Malpresentation Malpresentation Arrest in 1 st and 2 nd stage Arrest in 1 st and 2 nd stage Exclusion criteria Exclusion criteria Elective or non-urgent cesarean section Elective or non-urgent cesarean section

7. Statistics Mean and Standard Deviations for time to C/S Mean and Standard Deviations for time to C/S Pearson correlations calculated between outcome variables (1 and 5 minute Apgar and pH) and time to C/S. Pearson correlations calculated between outcome variables (1 and 5 minute Apgar and pH) and time to C/S. One-way ANOVA to analyze the change between shifts and time to C/S. One-way ANOVA to analyze the change between shifts and time to C/S.

8. Results 100 patients - one outlier was removed 100 patients - one outlier was removed The time to C/S was 695 minutes for the 1 outlier patient (8 standard deviations from the mean) The time to C/S was 695 minutes for the 1 outlier patient (8 standard deviations from the mean) Indication was 1 st stage arrest, there was no documented fetal distress or maternal fever Indication was 1 st stage arrest, there was no documented fetal distress or maternal fever

9. Results Maternal age 25±5 years Maternal age 25±5 years Gestational age 38±4 Gestational age 38±4 Indication for C/S: Indication for C/S: Fetal 22.2% Fetal 22.2% Maternal 19.2% Maternal 19.2% Malpresentations 7.1% * Malpresentations 7.1% * 2 nd stage arrest 21.2% 2 nd stage arrest 21.2% 1 st stage arrest 22.2% 1 st stage arrest 22.2%

10. Results Mean time to C/S - 97±73 minutes Mean time to C/S - 97±73 minutes With First Stage Arrests removed, mean = 99±77 With First Stage Arrests removed, mean = 99±77 Time to C/S varied with shift time - evening shift being significantly longer. Time to C/S varied with shift time - evening shift being significantly longer. 4pm-midnight: 119±93 min compared to 76±46 (8-4pm) and 81±42 (midnight-8am) 4pm-midnight: 119±93 min compared to 76±46 (8-4pm) and 81±42 (midnight-8am)

11. Time to C/S in relation to time the decision made

12. Results Mean time (min) to C/S by indication Mean time (min) to C/S by indication Fetal indications 75±50 Fetal indications 75±50 Maternal indications 138±93 Maternal indications 138±93 Malpresentations 140±126 * Malpresentations 140±126 * 2 nd stage arrest 80±51 2 nd stage arrest 80±51 1 st stage arrest 91±61 1 st stage arrest 91±61 *insufficient numbers in this group for statistical significance

13. Time to C/S by indication

14. Results A statistically significant difference was noted between maternal indications and fetal indications A statistically significant difference was noted between maternal indications and fetal indications

15. Correlation between time to C/S and 1 min Apgar

16. Correlation between time to C/S and 5 min Apgar

17. Correlation between time to C/S and cord pH

18. Results There was no correlation between time to C/S and any of the 3 fetal outcomes There was no correlation between time to C/S and any of the 3 fetal outcomes

19. Limitations of Study Documentation: Only 35% of charts had a note documenting the reason for C/S prior to the operation Documentation: Only 35% of charts had a note documenting the reason for C/S prior to the operation A best estimate for decision time had to be used in the majority of cases A best estimate for decision time had to be used in the majority of cases Prep for OR Prep for OR Doctor in to see patient Doctor in to see patient Nurse noting decision was best option Nurse noting decision was best option

20. Limitations of Study Fetal outcomes measured are limited Fetal outcomes measured are limited Further study looking at 28 day mortality, NICU admission, need for resuscitative intervention, and neurologic development would all be useful Further study looking at 28 day mortality, NICU admission, need for resuscitative intervention, and neurologic development would all be useful Maternal outcomes such as fever, recovery time and intrapartum stress were not reviewed Maternal outcomes such as fever, recovery time and intrapartum stress were not reviewed

21. Conclusion Time to C/S was greater than the 30 minute guideline recommended Time to C/S was greater than the 30 minute guideline recommended There is room for improvement with particular emphasis on the evening shift There is room for improvement with particular emphasis on the evening shift The difference between maternal vs. fetal indications for time to C/S may be due to the spectrum of maternal disease (clinical judgement) The difference between maternal vs. fetal indications for time to C/S may be due to the spectrum of maternal disease (clinical judgement)

22. Conclusion Longer time to C/S does not correlate with poor fetal outcome when appropriate clinical judgement and prioritization is made by physician Longer time to C/S does not correlate with poor fetal outcome when appropriate clinical judgement and prioritization is made by physician Further study needed - 30-minute guideline will likely need revision for time and also stratification by indication and gestational age Further study needed - 30-minute guideline will likely need revision for time and also stratification by indication and gestational age

23. References 1. Liu, S., Rusen, I.D., Joseph, K.S., Kramer, M.S., Wen, S.W., Kinch, R., Rechen trends in caesarean delivery rates and indications for caesarean delivery in Canada. J. Obs. Gynae. Can. 2004; 26(8): 735-42. 2. Society of Obstetrics and Gynecology, guideline 155, Feb 2005: http://www.sogc.org/jogc/pdf/abstracts/200502%2Dmartel.pdf http://www.sogc.org/jogc/pdf/abstracts/200502%2Dmartel.pdf 3. Victory, R., Penava, D., da Silva, O., Natale, R., Richardson, B. Umbilical Cord pH and Base Excess Values in Relation to Adverse Outcome Events for Infants Delivering at Term. Am. J. Obs. Gyne. 2004; 191: 2021-8. 4. Casey, B.M., McIntire, D.D., Leveno, K.J. The Continuing Value of the Apgar Score for the Assessment of Newborn Infants. NEJM. 2001; 344(7): 467-71. 5. Nasrallah, RK., Harirah, H.M., Vadhera, R., Jain, V., Franklin, L.T. Hankins, G.D.V. The 30-Minute Decision-to-Incision Interval for Emergency Cesarean Delivery: Fact or Fiction? Am. J. of Perinatology. 2004; 21(2):63-68. 6. Thomas, J., Paranjothy, S., James, D. National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section. BMJ 2004; 328(7441): 665-70 7. Bloom, S.L., et al. Decision-to-Incision Times and Maternal and Infant Outcomes. Obstetrics & Gynecology. 2006; 108(1): 6-11.

24. Thanks to … Dr. Lynn Murphy-Kaulbeck (supervisor) Dr. Lynn Murphy-Kaulbeck (supervisor) Michelina Mancuso Michelina Mancuso Medical records staff at Moncton City Hospital Medical records staff at Moncton City Hospital